Commissioning new services in the NHS: a game without rules[1]

“In that direction,” the cat said, waving its right paw around, “lives a Hatter: and in that direction,” waving the other paw, “lives a March Hare. Visit either if you like: they’re both mad.”

“But I don’t want to go around among mad people,” Alice remarked.

“Oh, you can’t help that,” said the cat: “we’re all mad here. I’m mad. You’re mad.”

“How do you know I’m mad?” said Alice.

“You must be,” said the Cat, “or you wouldn’t have come here.”[2]

The National Health Service is Wonderland. Whether it is run by the Hatter on the right or the March Hare on the left it has always been underfunded. The Fourth Annual Report of the Sidcup and Swanley Hospital Management committee in 1952 stated:

The year under review was again difficult, owing to the ceiling placed on expenditure… and it was apparent from the outset that it would not be possible to provide adequate services within the sum allotted… In response to the appeal of the Minister of Health for economy, all demands for expenditure have been strictly scrutinised and many economies have been effected.

If every demand is met, the pit of resources needs to be bottomless, so it comes as something of an irritation to be told by outsiders that more and more can be done without more and more cash. There is much pontification by those that don’t know and won’t listen. When things do go wrong (and the lack of neurosurgical intensive care beds in London so that a Sidcup patient was once flown to Leeds is an example) politicians move with unbelievable speed to blame the doctors.

Doctors are expected to be perfect, but are not given the wherewithal so to be. The new NHS has failed to free hospitals from any of the old constraints on development. Indeed in many respects it has made things worse. The rise of a new management bureaucracy has failed to streamline or speed up decision making and decisions are still made, (or as is more often the case not made) as a result of political expediency. All planning is based on yearly contracts and the NHS is supposed to run as a business. It cannot. The catchphrase is “money follows the patient”; so no patient, no money. But if there is no money, there can be no patient. Someone somewhere has forgotten that new businesses need money up front.

Suppose then that I, as a clinician, wish to develop a new service. I start by defining the clinical need— in my case the absence of facilities for brain injury rehabilitation in South East London and Kent. The service is specialised, and no single small district could justify a single unit for itself, so a unit to serve a wider area is planned. The combination of physical and psychological disturbance in patients with head injuries requires a labour-intensive approach, so staff costs are very high for small numbers of patients. In other words, this is a high-cost, low-volume service.

Models of care at home and abroad are examined. The unit can serve also as a base for research and education of NHS staff; these costs are included. Direct estimates of need are prepared by consulting clinicians who receive such patients— neurosurgeons, orthopaedic surgeons and rehabilitation specialists. The final capital and revenue costs are identified and the business case finalised.

But there it stops. The proposal is aired before the several Commissioning Agencies. They accept the projections of the numbers of patients likely to need the service. “But” they say, “we cannot commit ourselves to buying this service, because we can’t see what you are offering. And of course we would only meet the service costs, not the costs of education and research.”

“But,” I say, “money follows the patient. So without the money I can’t offer the service in the first place. And proper education and research will help us all to develop.”

“Well, we’re very sorry” they say, “but we won’t buy a service sight unseen.”

“But there isn’t any service at all anywhere and if you don’t commit the money there never will be a service.”

Gallic shrugs. And you can hear them counting the number of hip replacements they won’t have to leave unfunded. “That’s your problem, not ours.”

Which it is, of course.[3] I would be mad to set up a costly service without a commitment to use it. Managers are of course immune from this Cheshire Cat Catch-22; several dozen millions of pounds followed Wessex Regional Health Authority’s computers down the plughole.

The government has made an effort to bring in pump-priming money to solve this

sort of problem with an exercise called the Private Finance Initiative. Its first impact was to blight several projects already in the pipeline, as they had to be held up while they went through the new procedure. I had high hopes of priming the brain injury rehabilitation project this way, until Mrs Margaret Beckett announced in the House that companies committing their assets to this kind of scheme might, under a Labour government, have them confiscated.[4] Hands up those who think the next government won’t be a Labour government. So private investors run a mile, given such a friendly guarantee, and the system is itself Catch-22— damned if you don’t use private funds, and potentially damned if you do.

A further perturbation is introduced by the rise and rise of General Practitioner fundholding[5]. The commissioning of specialist low-volume services on behalf of small populations results in wild and unpredictable fluctuations in contract demand. Add to that the possibility that contracts may be moved between providers on a yearly basis and any possibility of strategic planning vanishes. The uncertainty of the contracting process makes it difficult to reassure staff that their future is secure; a workforce that is constantly on the hop is a deeply unhappy workforce, and becomes uncommitted and unproductive[6]. Certainly much of the unrest in the NHS today is engendered by the fickle, almost ephemeral nature of the purchaser- provider system with contracts that may be here today and gone tomorrow. Patients with chronic diseases do not have sell-by dates and to encourage a system that jumps their care from place to place is as unkind as it is absurd.

The commissioning of new services is caught by Catch-22, but even the development of existing services is constrained. My department received more outpatient referrals weekly than there are clinic slots. I do more clinics than the national average already, so to meet the demand extra staff are needed. The situation has been exacerbated temporarily by the closure of the Queen Elizabeth Military Hospital, which has been providing a rheumatology service to the locality for years at no cost to the NHS; all the patients under regular review with chronic arthritis are being discharged to have follow-up elsewhere, and we expect about a hundred complex patients all at once. No money comes with them, let alone follows them. To accommodate them, other referrals have to be put off. The waiting time for a new appointment lengthens and Patients’ Charter goes through the window. A business case for a new consultant is put, but the Commissioning Agency has no money to fund the extra work, unless it takes it from another area. So, on the one hand we are faced with a demand for appointments that we cannot meet, while on the other we are denied the funds to meet them (and the redundant consultants from the Military Hospital are still out of a job).

What then is the answer? Overt or covert rationing will not go away. Neither will gratuitous waste. Wessex’s computers apart, I am told that £6 million would have been saved if the Department of Health had spoken to the Department of the Environment before forging ahead with plans for a new hospital for Bromley on a Green Belt site— which the DoE turned down; half a million was blown at the Brook Hospital in Greenwich on a magnetic resonance imaging scanner that never worked[7]. It’s well to remember that these expenditures were never sanctioned by doctors.

Firstly it is up to government to concede that its financial commitment to the NHS never has met and never will meet the demand, and stop playing the game of the Emperor’s clothes[8]. Secondly the contracting system must be stabilised so that long- term strategic planning is not blighted; and the wasteful duplication of the contracting bureaucracy, with negotiators in every hospital and General Practice, must be abolished. Thirdly a sensible pump-priming system for new developments must be introduced— one which is not prey to political dogma. Fourthly, it’s time to stop knocking doctors, and time to listen to what they say. I believe that the patience of the medical profession, and its steadfast attempt to continue to be positive in the face of constant sniping and senseless change, caught between the rock of patient demand and the hard place of underfunding, is little short of miraculous. But then, like the Cheshire Cat, we are all mad here.

[1] I include this essay as an example of several phenomena – the enduring nature of politicians’ desires to fiddle with the NHS, their deceit (by making statements they abandon), the innate immovability of an over-bureaucratised system, and censorship. I was asked to write the piece by a magazine for MPs called “The Parliamentarian”, which offered me a fee, accepted the article and then not only refused to publish it, without giving any reasons, but didn’t pay either. It may seem a little dated now, but it was written in 1994. I reworked it for a Personal View which did appear in the British Medical Journal (Bamji AN. Brain injury rehabilitation: jaw-jaw not war-war, BMJ 1996; 312: 916-7)

[2] Lewis Carroll, Alice in Wonderland

[3] And remains so; 17 years later there is still no specialised brain injury unit provided by the NHS in South London

[4] Two points here; I didn’t at this time realise how PFIs would be set up, so thought they would be like decent house mortgages; and Mrs Beckett’s threat was not only not carried out but positively reversed, as the incoming Labour government saw a great opportunity to expand the NHS on the never-never, in a completely unaffordable way as we shall see, and yet keep the expenditure off the government balance sheet.

[5] Later abolished, but resurrected in a slightly different form by the Coalition government of 2010

[6] This is exactly what happened – again – in 2010 as the result of financial cuts, outsourcing and tendering. Plus ça change…

[7] It was designed to go into a temporary building, which was not solid enough to damp out the vibrations generated during the scanning process as the magnet switched on and off. Furthermore it was purchased from the USA second-hand; it was assumed that its previous usage pattern was what it would have been in the UK (about 6 hours per day) but it had in fact been used regularly for over 20 hours a day, so was pretty clapped out.

[8] An analogy I repeated in an article in 2007 (The Emperor’s new business clothes (Bamji AN. British Journal of Healthcare Management 2007; 13: 294-297)



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